Staff Summer Camp Registration

By checking this box, I consent to any x-ray, anesthetic, medical, surgical, or dental treatment that may be deemed necessary for myself. In the event of an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat me. I further understand that that the doctors, dentists and other providers attending to me will take all reasonable safety precautions during their care. Further, I am responsible for the health care decisions for myself and agree that my insurance plan is the primary plan to pay for the dental, medical or hospital care or treatment that is given to my child. No coverage is being provided by event sponsoring entities.

By checking this box, I give my consent for my minor/child to participate in the Hearts for Hearing Summer Camp Program. I understand that all reasonable safety precautions will be taken by the leaders of this activity, and that the possibility of an unforeseen hazard does exist. I further agree not to hold Hearts for Hearing and any affiliates, its leaders, employees, volunteer staff liable for damages, losses, diseases, or injuries incurred by the minor listed above.

By checking this box, I grant permission to Hearts for Hearing to use the photograph/video of me for unlimited use in any Hearts for Hearing publication, periodical, brochure, display, booklet, video, documentary, commercial, or TV project. I hereby grant Hearts for Hearing exclusive rights to the use of any video/photograph and/or its negative any way it should deem appropriate to further its goal of increasing public awareness and education, and/or to increase opportunities for individuals who are hearing impaired.

By checking this box, I agree that as a visitor, student, volunteer, former or current employee of Hearts for Hearing, I will not disclose any information which comes to me through the carrying out of my assigned duties/program or assignment while at this location.

By checking this box, I agree that I will not contact any individual or agency outside of this program to get personal information about an individual patient unless a release of information has been requested by the physician and signed by the patient, significant other, or parent/guardian. I will not carry over my relationship with a patient in my off-duty hours.